Aortic valve surgery - minimally invasive

Before your surgery, you will receive general anesthesia.

You will be asleep and pain-free.

There are several ways to do minimally invasive aortic valve surgery. Techniques include min-thoracotomy, min-sternotomy, robot-assisted surgery, and percutaneous surgery. To perform the different procedures:

• Your surgeon may make a 2-inch to 3-inch (5 to 7.6 centimeters) cut in the right part of your chest near the sternum (breastbone). The muscles in the area will be divided. This lets the surgeon reach the heart and aortic valve.
• Your surgeon may split only the upper portion of your breast bone, allowing exposure to the aortic valve.
• For robotically-assisted valve surgery, the surgeon makes 2 to 4 tiny cuts in your chest. The surgeon uses a special computer to control robotic arms during the surgery. A 3D view of the heart and aortic valve are displayed on a computer in the operating room.

You may need to be on a heart-lung machine for all of these surgeries.

When the aortic valve is too damaged for repair, a new valve is put in place. Your surgeon will remove your aortic valve and sew a new one into place. There are two main types of new valves:

• Mechanical, made of man-made materials, such as titanium or carbon. These valves last the longest. You will need to take blood-thinning medicine, such as warfarin (Coumadin), for the rest of your life if you have this type of valve.
• Biological, made of human or animal tissue. These valves last 10 to 20 years, but you may not need to take blood thinners for life.

Another technique is transcatheter aortic valve replacement (TAVR). TAVR can be done through a small incision made in the groin or the left chest. The replacement valve is passed into the blood vessel or the heart and moved up to the aortic valve. The catheter has a balloon on the end. The balloon is inflated to stretch the opening of the valve. This procedure is called percutaneous valvuloplasty and allows for a new valve to be placed in this spot. The surgeon then sends a catheter with an attached valve and detaches the valve to take the place of the damaged aortic valve. A biological valve is used for TAVR. You do not need to be on a heart-lung machine for this procedure.

In some cases, you will have coronary artery bypass surgery (CABG), or surgery to replace part of the aorta at the same time.

Once the new valve is working, your surgeon will:

• Close the small cut to your heart or aorta
• Place catheters (flexible tubes) around your heart to drain fluids that build up
• Close the surgical cut in your muscles and skin

The surgery can take 3 to 6 hours, however, a TAVR procedure is often shorter.

Aortic valve surgery is done when the valve does not work properly. Surgery may be done for these reasons:

• Changes in your aortic valve are causing major heart symptoms, such as chest pain, shortness of breath, fainting spells, or heart failure.
• Tests show that changes in your aortic valve are harming the work of your heart.
• Damage to your heart valve from infection (endocarditis).

A minimally invasive procedure can have many benefits. There is less pain, blood loss, and risk for infection. You will also recover faster than you would from open heart surgery.

Percutaneous valvuloplasty and catheter-based valve replacement such as TAVR are done only in people who are too sick or at very high risk for major heart surgery. The results of percutaneous valvuloplasty are not long-lasting.

Risks of any surgery are:

• Bleeding
• Blood clots in the legs that may travel to the lungs
• Breathing problems
• Infection, including in the lungs, kidneys, bladder, chest, or heart valves
• Reactions to medicines

Other risks vary by the person's age. Some of these risks are:

• Damage to other organs, nerves, or bones
• Heart attack, stroke, or death
• Infection of the new valve
• Kidney failure
• Irregular heartbeat that must be treated with medicines or a pacemaker
• Poor healing of incision
• Death

Always tell your health care provider:

• If you are or could be pregnant
• What medicines you are taking, even drugs, supplements, or herbs you bought without a prescription

You may be able to store blood in the blood bank for transfusions during and after your surgery. Ask your provider about how you and your family members can donate blood.

For the week before surgery, you may be asked to stop taking medicines that make it harder for your blood to clot. These might cause increased bleeding during the surgery.

• Some of them are aspirin, ibuprofen (Advil, Motrin), and naproxen (Aleve, Naprosyn).
• If you are taking warfarin (Coumadin), clopidogrel (Plavix), or other blood thinning medicine, talk with your surgeon before stopping or changing how you take these drugs.

During the days before your surgery:

• Ask which medicines you should still take on the day of your surgery.
• If you smoke, you must stop. Ask your provider for help.
• Always let your provider know if you have a cold, flu, fever, herpes breakout, or any other illness in the time leading up to your surgery.

Prepare your house for when you get home from the hospital.

Shower and wash your hair the day before surgery. You may need to wash your body below your neck with a special soap. Scrub your chest 2 or 3 times with this soap. You also may be asked to take an antibiotic to prevent infection.

On the day of your surgery:

• You may be asked not to drink or eat anything after midnight the night before your surgery. This includes using chewing gum and mints. Rinse your mouth with water if it feels dry. Be careful not to swallow.
• Take the medicines you have been told to take with a small sip of water.
• You will be told when to arrive at the hospital.

After your operation, you will spend 3 to 7 days in the hospital. You will spend the first night in an intensive care unit (ICU). Nurses will monitor your condition at all times.

Most of the time, you will be moved to a regular room or a transitional care unit in the hospital within 24 hours. You will start activity slowly. You may begin a program to make your heart and body stronger.

You may have two or three tubes in your chest to drain fluid from around your heart. Most of the time, these are taken out 1 to 3 days after surgery.

You may have a catheter (flexible tube) in your bladder to drain urine. You may also have intravenous (IV) lines for fluids. Nurses will closely watch monitors that display your vital signs (pulse, temperature, and breathing). You may have daily blood tests and ECGs to test your heart function until you are well enough to go home.

A temporary pacemaker may be placed in your heart if your heart rhythm becomes too slow after surgery.

Once you are home, recovery takes time. Take it easy, and be patient with yourself.

Mechanical heart valves do not fail often. However, blood clots can develop on them. If a blood clot forms, you may have a stroke. Bleeding can occur, but this is rare.

Biological valves have a lower risk for blood clots, but tend to fail over time. Minimally invasive heart valve surgery has improved in recent years. These techniques are safe for most people and can reduce recovery time and pain. For best results, choose to have your aortic valve surgery at a center that does many of these procedures.

Mini-thoracotomy aortic valve replacement or repair; Cardiac valvular surgery; Mini-sternotomy; Robotically-assisted aortic valve replacement; Transcatheter aortic valve replacement

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Hisamoto K, Sin DN, Williams MR. Role of the cardiac surgeon and the heart team. In: Topol EJ, Teirstein PS, eds. Textbook of Interventional Cardiology. 8th ed. Philadelphia, PA: Elsevier; 2020:chap 33.

Lamelas J. Minimally invasive, mini-thoracotomy aortic valve replacement. In: Sellke FW, Ruel M, eds. Atlas of Cardiac Surgical Techniques. 2nd ed. Philadelphia, PA: Elsevier; 2019:chap 10.

Malaisrie SC, McCarthy PM. Surgical approach to diseases of the aortic valve and aortic root. In: Otto CM, Bonow RO, eds. Valvular Heart Disease: A Companion to Braunwald's Heart Disease. 5th ed. Philadelphia, PA: Elsevier; 2021:chap 14.

Updated by: Mary C. Mancini, MD, PhD, Cardiothoracic Surgeon, Shreveport, LA. Review provided by VeriMed Healthcare Network. Also reviewed by David C. Dugdale, MD, Medical Director, Brenda Conaway, Editorial Director, and the A.D.A.M. Editorial team.