Aortic Valve Replacement

An aortic valve replacement is used to treat conditions affecting the aortic valve. These are known as aortic valve diseases.

The two main aortic valve diseases are:

• aortic stenosis – where the valve is narrowed, restricting blood flow
• aortic regurgitation – where the valve allows blood to leak back into the heart

These problems can be something you're born with, or can develop later in life.

Causes of aortic valve disease

Some of the main causes include:

• senile aortic calcification – where calcium deposits form on the valve as you get older, preventing it from opening and closing properly
• bicuspid aortic valve – a problem present from birth, in which the aortic valve only has two flaps instead of the usual three, which can cause problems as you get older
• underlying conditions that can damage the aortic valve – including Marfan syndrome, Ehlers-Danlos syndrome, rheumatic fever, lupus, giant cell arteritis and endocarditis

Problems caused by aortic valve disease

If you have aortic valve disease, you may not experience any symptoms at first. However, the condition can eventually become more severe and cause:

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

In particularly serious cases, aortic valve disease can lead to life-threatening problems such as heart failure.

When surgery is recommended

If you have an aortic valve disease and you have no or only mild symptoms, you'll probably just be monitored to check whether the condition is getting worse.

If your symptoms become more severe, you'll probably need surgery to replace the valve. Without treatment, severe aortic valve disease is likely to get worse and may eventually be fatal.

Aorta
The aorta is a large blood vessel that runs down the abdomen and transports blood away from the heart.

Aortic valve
The aortic valve is the valve that controls the flow of blood out of the left ventricle of the heart to the aorta.

Ultrasound scan
An ultrasound scan, sometimes called a sonogram, is a procedure that uses high-frequency sound waves to create an image of part of the inside of the body, such as the heart.

An aortic valve replacement is a major operation and will only be carried out if you're well enough to have surgery.

Preparing for the operation

In the weeks before the procedure, you'll attend a pre-admission clinic for an assessment to check whether the operation is suitable. This is also a good time to ask any questions you have about the procedure.

As part of this assessment, you may:

• have a physical examination
• be asked about your medical history, including any medication you're taking, any allergies you have and whether you've had a reaction to anaesthesia in the past
• have tests to check your general and heart health – these may include a blood test, X-ray, electrocardiogram (ECG) and/or echocardiogram

If you smoke, you'll be advised to stop in the lead up to your operation because this can reduce the risk of complications. You should be told when you need to stop eating and drinking before the procedure.

When you have the operation, it's likely you'll be in hospital for about a week, so you'll need to make some practical preparations in advance. These include bringing clothes, toiletries and any equipment you use, such as a walking stick or hearing aid.

Read more about going into hospital and preparing for surgery.

The operation

An aortic valve replacement is carried out under general anaesthetic. This means you'll be asleep during the operation and won't feel any pain while it's carried out. The operation usually lasts a few hours.

During the procedure:

• a large cut (incision) around 25cm long will be made along the middle of your breastbone to allow the surgeon access to your heart, although in some cases a smaller cut may be made
• tubes are inserted into your heart and major blood vessels, which are attached to a heart-lung (bypass) machine – this will take over the job of your heart during the operation
• medication is used to stop your heart and your main artery (aorta) is clamped shut – this allows your surgeon to open your heart and operate on it without blood pumping through
• the aorta is opened up and the damaged aortic valve is removed
• the new valve is sewn in place with a fine thread
• your heart is started again using controlled electric shocks, before you're taken off the bypass machine
• your breastbone is joined up with wires, and the wound on your chest closed using dissolvable stitches

Choice of valve replacement

Before having an aortic valve replacement, you'll need to decide on the most suitable type of replacement valve for you.

There are two main types of replacement valve:

• mechanical valves – made of synthetic materials
• biological valves – made of animal tissue

Each type has advantages and disadvantages, which your doctor will discuss with you.

Mechanical valves

The main advantage of mechanical valves is that they're hard-wearing and less likely to need replacing. This means they're often better for younger people having a valve replacement.

However, there's a tendency for potentially dangerous blood clots to form on the valve, so lifelong treatment with anticoagulant medication such as warfarin is needed to prevent this.

This will increase the chances of excessive bleeding from a cut or injury, particularly as you get older, and may not be suitable if you've had significant bleeding problems in the past.

Mechanical valves can also make a quiet clicking noise, which can be disturbing at first, but is easy to get used to.

Biological valves 

The main advantage of biological valves is that there's less risk of clots forming, so lifelong anticoagulant treatment isn't usually necessary.

However, biological valves tend to wear out a bit faster than mechanical valves and may eventually need to be replaced after many years. Therefore, they are often better for older people having a valve replacement.

Aorta
The aorta is a large blood vessel that runs down the abdomen and transports blood away from the heart.

Aortic valve
The aortic valve is the valve that controls the flow of blood out of the left ventricle of the heart to the aorta (the body’s main artery).

Bypass
A bypass is when the flow of blood or other fluid is redirected, permanently because of a blockage in the body or temporarily during an operation.

Blood vessel
Blood vessels are the tubes in which blood travels to and from parts of the body. The three main types of blood vessels are veins, arteries and capillaries.

Incision
An incision is a cut made in the body with a surgical instrument during an operation.

After an aortic valve replacement, you'll usually need to stay in hospital for about a week.

The time it takes to fully recover varies depending on factors such as your age and overall health.

Your breastbone will usually heal in about six to eight weeks, but it may be two to three months before you feel your normal self again.

Recovering in hospital

You'll usually stay in an intensive care unit (ICU) for the first day or two after your operation, before moving to a surgical ward.

Staying in an ICU

While you're in the ICU:

• you may be kept asleep for the first few hours, or until the following morning
• the activity of your heart, lungs and bodily functions will be closely monitored
• you'll be given painkillers for when your anaesthetic wears off – let a nurse or the doctor in charge of your care know if these aren't helping
• a tube attached to a ventilator will be placed down your throat until you're able to breathe on your own – this may be uncomfortable and you won't be able to talk, eat or drink while it's in place

When you're taken off the ventilator, a mask will be placed over your mouth and nose to supply oxygen for you to breathe.

Moving to a ward

You'll be moved from the ICU to a surgical ward once the doctors treating you think you're ready.

You may have several tubes and monitors attached to you during the first few days of your stay. These could include:

• chest drains – small tubes from your chest to drain away any build-up of blood or fluid
• pacing wires – if necessary, these will be inserted near the chest drains to control your heart rate
• wires attached to sensor pads – these can be used to measure your heart rate, blood pressure and blood flow, and the air flow to your lungs
• a catheter – a tube inserted into your bladder so that you can pass urine

Your care team will focus on increasing your appetite and getting you back on your feet.

Someone from the cardiac rehabilitation team or physiotherapy department will give you advice about getting back to normal, and where there is a cardiac rehabilitation programme or support group in your area.

The aim is to help you recover quickly and get back to living as full and active a life as you can, while preventing further heart problems.

Going home

Depending on how well you progress, you should be able to leave the hospital about a week after your operation.

Before going home, you'll be given advice about caring for your wound and any activities you need to avoid until you've recovered.

Returning to your normal activities

You'll need to take things easy at first. Starting gentle exercise such as walking can be helpful when you feel up to it, but don't try to do too much too quickly.

Your doctor or surgeon can give you specific advice about when you can return to your normal activities, but generally speaking:

• you can be a passenger in a car straight away
• you may not be able to drive for around six weeks – wait until you can comfortably do an emergency stop
• you can have sex after four to six weeks – make sure you feel strong enough first
• when you can return to work depends on the type of work you do – this could be as soon as six to eight weeks if your job mainly involves light work, but may not be for three months if it involves manual labour
• you should avoid strenuous exercise, sudden strains and heavy lifting for three months

Possible side effects

While at home, you may experience some temporary side effects that should start to improve as you recover. These can include:

• pain and discomfort – you can take painkillers to relieve this, although it should improve as your wound heals
• swelling and redness around your wound that should gradually fade
• loss of appetite
• difficulty sleeping (insomnia)
• constipation – drinking plenty of fluids and eating fruit and vegetables can help with this; your doctor may also suggest taking a laxative
• mood swings, irritability, anxiety and depression – these are completely normal after major surgery; talking to your friends and family can help, and your cardiac nurse can also offer support
• loss of interest in sex – this is common in people with serious illnesses; in men, the associated emotional stress can also result in erectile dysfunction

Speak to your GP or cardiac nurse for advice if you're struggling to cope with the after effects of your operation or they don't seem to be improving.

When to get medical advice

Contact your GP if you experience:

• increasing redness, swelling or tenderness around the wound
• pus or fluid oozing from the wound 
• pain that's getting worse
• a high temperature of 38C (100.4F) or above
• increasing shortness of breath
• a return of the symptoms you had before the operation

These symptoms could be a sign of a problem such as an infection. Read more about the risks of an aortic valve replacement.

Aortic valve
The aortic valve is the valve that controls the flow of blood out of the left ventricle of the heart, to the aorta (the body’s main artery).

Like any type of surgery, an aortic valve replacement is associated with a number of complications. Fortunately, serious problems are uncommon.

The risk of experiencing complications is generally higher for older people and those in generally poor health.

Possible problems include:

• Infection – there's a risk of wound infections, lung infections, bladder infections and heart valve infections (endocarditis). You may be given antibiotics to reduce this risk.
• Excessive bleeding – tubes may be inserted into your chest to drain the blood, and sometimes another operation is needed to stop the bleeding.
• Blood clots – this is more likely if you have had mechanical valve replacement. You'll be prescribed anticoagulant medication if you're at risk.
• Stroke or transient ischaemic attack (TIA) – where the supply of blood to the brain becomes blocked.
• The valve may wear out – this is more likely in people who have had a biological valve replacement for a long time.
• Irregular heartbeat (arrhythmia) – this affects around 25% of people after an aortic valve replacement and usually passes with time. However, 1-2% of people will need to have a pacemaker fitted to control their heartbeat.
• Kidney problems – in up to 5% of people, the kidneys do not work as well as they should for the first few days after surgery. In a few cases, temporary dialysis may be needed.

An aortic valve replacement is a major operation and occasionally the complications can be fatal. Overall, the risk of dying as a result of the procedure is estimated to be 1-3%.

However, this risk is far lower than the risk associated with leaving severe aortic disease untreated.

Aortic valve
The aortic valve is the valve that controls the flow of blood out of the left ventricle of the heart, to the aorta (the body’s main artery).

Stroke
A stroke is a serious medical condition that occurs when the blood supply to the brain is disturbed or restricted. Brain cells begin to die and this can lead to brain damage and possibly death.

Aortic valve replacement is the most effective treatment for aortic valve diseases. However, it can place tremendous strain on the body and alternatives procedures may be needed.

The main procedures that may be recommended for people who aren't in good enough overall health to have a conventional aortic valve replacement are outlined below.

Aortic valve balloon valvuloplasty

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

This can help treat a narrowed aortic valve (aortic stenosis), but doesn't help with a leaky aortic valve (aortic regurgitation).

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

The main drawback with this type of treatment is that the effects may only last for up to a year. After this, further treatment is needed.

Transcatheter aortic valve implantation (TAVI)

Transcatheter aortic valve implantation (TAVI) involves inserting a catheter into a blood vessel in your upper leg or chest and passing it towards your aortic valve. The catheter is then used to guide and fix a replacement valve over the top of the old one.

The main advantages of this technique are that the heart doesn't need to be stopped, so a heart-lung (bypass) machine doesn't need to be used, and it avoids making a large cut (incision) in your chest.

This puts less strain on the body and may mean TAVI is more suitable for people who are too frail to have a conventional valve replacement.

Research suggests the procedure may be as effective as surgery for people in whom surgery would be difficult or risky, and it may result in a faster recovery. But there's little evidence to suggest it's appropriate for people who are suitable for surgery and at a low risk of complications.

Possible complications of TAVI are similar to those of a conventional valve replacement, although the risk of having a stroke after TAVI is higher.

Sutureless aortic valve replacement

Sutureless aortic valve replacement is the newest alternative to traditional open surgery. The main difference between the two procedures is that there are no stitches (sutures) used to secure the replacement valve in place.

The aim of this procedure is to minimise the amount of time the operation takes, so there is less time spent on a bypass machine. It may be an option for people who have a high risk of complications during the standard procedure.

As the procedure is relatively new, the long-term effects are not yet fully known. However, it's thought that the main risks of this treatment are blood leaking around the replacement valve or a blood clot forming.

A leak may mean the procedure has to be repeated to fix the problem, or an alternative treatment may be used. If a blood clot forms, the person could have a stroke.

Aortic valve
The aortic valve is the valve that controls the flow of blood out of the left ventricle of the heart, to the aorta (the body’s main artery).

Arteries
Arteries are blood vessels that carry blood from the heart to the rest of the body.

Blood vessel
Blood vessels are the tubes in which blood travels to and from parts of the body. The three main types of blood vessels are veins, arteries and capillaries.